Οξεία Καρδιακή Ανεπάρκεια: Κλινική εικόνα, ταξινόμηση κινδύνου & προγνωστικοί δείκτες

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1 Οξεία Καρδιακή Ανεπάρκεια: Κλινική εικόνα, ταξινόμηση κινδύνου & προγνωστικοί δείκτες Στράτος Θεοφιλογιαννάκος, MD, PhD Ιατρείο Καρδιακής Ανεπάρκειας, Γ Πανεπιστημιακή Καρδιολογική Κλινική ΑΠΘ, ΠΓΝ Ιπποκράτειο & Κλινική Άγιος Λουκάς 01/03/2017

2 ACHF: De novo or Worsening HF Gheorghiade et al, JACC Vol. 53, No. 7, 2009 Ahgababian R. Rev Card Med. 2002

3 Clinical Characteristic of Acute Heart Failure Patients in Different Registries Farmakis et al, Rev Esp Cardiol. 2015;68(3):

4 Acute Heart Failure Subtypes Decompensated HF: dyspnoea or tachycardia and pulmonary congestion or interstitial oedema verified by chest X-ray Pulmonary oedema: HF accompanied by alveolar oedema in the chest X-ray or with O 2 saturation <90% (without supplemental oxygen) Cardiogenic shock: AHF accompanied by low blood pressure (SBP<90 mmhg) and oliguria (<0.5 ml/kg/h for at least 6 h) or low cardiac index (<2.2 L/min/m 2 ). HF and hypertension: high blood pressure (>180/100 mmhg) accompanied by symptoms of HF (dyspnoea and tachycardia) and radiological findings of pulmonary congestion or oedema and with preserved left ventricular (LV) function at index hospitalization or before. Right HF: HF due to right-sided pathophysiology with increased jugular venous pressure and liver size and usually accompanied by peripheral oedema as unique or concomitant to left HF. Acute Coronary Syndrome Complicated by Heart Failure: Up to 15% to 20% of patients admitted with ACS have signs and symptoms of heart failure and an additional 10% develop HF during hospital stay. MS. Nieminen et al, Eur Heart J (2006) 27 (22):

5 EuroHeart Failure Survey II The frequency of clinical subtypes of acute heart failure MS. Nieminen et al, Eur Heart J (2006) 27 (22):

6 Clinical profiles of patients with AHF Because AHF may comprise a wide spectrum of clinical conditions with different underlying pathophysiologies and precipitating factors, a patient admitted to hospital for AHF may have a variety of clinical manifestations. This classification may be helpful to guide therapy in the initial phase and carries prognostic information. ESC Heart Failure Guidelines 2016

7 Acute Heart Failure Outcome in Different Registries Farmakis et al, Rev Esp Cardiol. 2015;68(3):

8 Mortality Risk Factors in AHF Age NYHA Class Low Blood Pressure Higher Heart Rate Higher Respiratory Rate Increased BUN Increased Creatinine Hyponatremia Low Hemoglobin Higher Natriuretic Peptides High Troponin levels Low Ejection Fraction Higher Natriuretic Peptides Alain Cohen-Solal et al Archives of Cardiovascular Disease (2015)

9 Mortality Risk Factors in AHF Alain Cohen-Solal et al Archives of Cardiovascular Disease (2015)

10 Καρδιακή λειτουργία και ποιότητας ζωής AHF Mortality: De-novo Vs ADHF Χρόνια εξασθένιση Νοσηλείες για επεισόδια οξείας απορρύθμισης Gheorghiade and Pang. J Am Coll Cardiol The long-term prognosis after hospitalization for AHF is poor, with a significantly different survival observed in patients with de-novo AHF compared to ADCHF. A previous history of heart failure is an independent predictor of five-year mortality. Johan P.E. Lassus Int J Cardiol 2013

11 AHF Mortality depends on Clinical Presentation In-hospital mortality as a function of the past history and clinical presentation of acute heart failure EuroHeart Failure Survey II MS. Nieminen et al, Eur Heart J (2006) 27 (22):

12 Etiology and Prognosis of Heart Failure G. M Felker et al N Engl J Med 2000

13 Effect of Age on Long term survival in ADHF patients Older patients less frequently had LV systolic dysfunction, were under treated with ACE-inhibitors and were more often female. The prevalence of hypertension, diabetes and ischemic heart disease increased with age, until the oldest age group (>80 years). Age was an independent predictor of short-term mortality. Advancing age significantly increased long-term mortality.

14 In-hospital mortality for patients with HF based on sex and reduced vs preserved EF. Despite substantial differences in baseline characteristics, women and men with reduced and preserved EF have similar in hospital mortality during an admission for acute decompensated HF. EM. Hsich et al Am Heart J 2012;

15 Socioeconomic Status and Prognosis After Heart Failure Hospitalization Low socioeconomic status is associated with: higher HF incidence, higher rehospitalization, higher mortality Randi E. Foraker et al. Circ Heart Fail. 2011

16 Long-Term Survival for Patients with ADHF According to Ejection Fraction (HFPEF vs HFREF) Patients with ADHF experience high death rates after discharge from the hospital, regardless of EF findings. The highest post-discharge mortality rates were observed for patients with reduced EF. AH. Coles et al J Am Heart Assoc. 2015

17 RV Function and Left Sided Acute Decompensation of HF On Admission At discharge Group A: RVDd< 32 mm Group B: RVDd= mm Group C: RVDd> 40 mm According to the increase of RVDd category, the cardiac related death-free rate significantly decreased. RVDd on admission could be measured noninvasively and easily to predict a worse long term prognosis in patients with decompensated left sided heart failure. E Maekawa et al Int Heart J 2011

18 Comorbidities and Prognosis in AHF VM. van Deursen et al European Journal of Heart Failure 2013

19 Blood Pressure and prognosis in AHF Hypotension while hospitalized for acute decompensated HF is an independent risk factor for adverse 30-day outcomes, and its occurrence highlights the need for modified treatment strategies. While the majority of these episodes were asymptomatic, hypotension whether asymptomatic or symptomatic, was associated with worse 30-day outcomes. PA Patel et al Circ Heart Fail 2014

20 BMI Paradox in AHF 108,927 patients with Acute Heart Failure. Hospitalized patients with HF, higher BMI was associated with lower in hospital mortality risk. Fonarow et al Am Heart J 2007

21 Prognostic Value of Various Biomarkers Alain Cohen-Solal et al Archives of Cardiovascular Disease (2015)

22 Outcomes of Patients with Anemia and AHF (HFpEF Vs HFrEF) The incremental risks of death and lengthened hospital stay associated with anemia are more pronounced in ADHF patients classified with HFpEF than HFrEF. MC Caughey et al Am J Cardiol

23 Lower Serum Sodium Is Associated With Increased Short-Term Mortality in AHF In patients hospitalized for worsening heart failure, admission serum sodium is an independent predictor of increased number of days hospitalized for cardiovascular causes and increased mortality within 60 days of discharge. L Klein et al OPTIME-CHF Circulation 2005

24 Single baseline serum creatinine predict mortality in patients hospitalized for AHF In a large cohort of patients with mostly non-ischaemic AHF, enhanced serum creatinine levels and reduced egfr independently predict death. It appears that patients with egfr < 30 ml/min/1.73 m2 have poorest survival rates. JC Schefold et al ESC Heart Failure 2015

25 InHospital Mortality InHospital Mortality In-Hospital Mortality Risk by Initial BNP Levels- ADHERE Registry LVEF < ,8 P< ,8 6, LVEF > 0.40 P< ,7 2, , ,5 0 Q1 (<622) Q2 ( ) Q3 ( ) Q4 (>2310) 0 Q1 (<336) Q2 ( ) Q3 ( ) Q4 (>1230) Fonarow GC et al. J Am Coll Cardiol 2007

26 Cardiac Troponin and Outcome in Acute Heart Failure Peacock et al. N Engl J Med 2008;358:

27 Higher CRP Predicts Worse Prognosis in AHF in Noninfected Patients In patients with infection, CRP was not a good predictor of adverse outcome. Noninfected patients with higher CRP at discharge had worse prognosis. P Lourenco et al Clin Cardiol 2010

28 Risk Scores What we need for the optimal Risk Score? The parameters of the models should fulfil the following criteria: a) wide availability, b) easy obtainability, c) low cost, and d) previously documented value as prognostic marker in AHF. Risk Scores: Acute Vs Chronic Heart Failure Xanthopoulos et al, Int J Cardiol 2016 Τhe phenomenon of reverse epidemiology has been described, in which directionally opposite effects of prognostic factors has been observed between the acute and chronic settings. An example of this concept is illustrated by systolic blood pressure. Specifically, higher systolic blood pressure is a prognostic factor that is protective in the acute setting, but has an adverse effect on outcomes in those with stable HF.

29 RISK SCORES- In-hospital mortality A Passantino et al World J Cardiol 2015

30 Risk Stratification in AHF- ADHERE Registry hospitalizations for AHF. 46% had HFPF. 39 variables was tested. Overall, in-hospital mortality was 4.1%. Mortality risk varied more than 10-fold (from 2.1% to 21.9%) based on: 1. the patient s initial SBP 2. levels of BUN and 3. levels of creatinine. ADHERE risk tree GC Fonarow et al JAMA 2005

31 Risk Stratification in AHF- OPTIMIZE HF Registry Risk of in-hospital mortality for patients hospitalized with HF remains high and is increased in patients who are: older with low SBP with low sodium levels with elevated heart rate with creatinine at admission. OPTIMIZE-HF Registry JACC Vol. 52, No. 5, 2008

32 The GWTG (Get With The Guidelines)-HF risk score Age, systolic blood pressure, blood urea nitrogen, heart rate, sodium, chronic obstructive pulmonary disease, and nonblack race were predictive of inhospital all-cause mortality. PN. Peterson et al Circulation 2010

33 Acute Heart Failure Index AHF Index is a tree-based model, which includes a large number of variables to assess risk of in-hospital death. J Hsiao et al Emerg Med J 2012;

34 RISK SCORES- Post-discharge mortality A Passantino et al World J Cardiol 2015

35 Risk Stratification in AHF- Effect Score Retrospective study of 4031 patients presenting with AHF from Main outcome: 30-day & 1-year mortality. DS Lee et al JAMA 2003

36 AHF risk score, AHFRS AHFRS can be easily memorized and obtained at admission without the use of a calculator and has the potential to predict the outcome of AHF patients (all-cause mortality or rehospitalization for HF at one year). Multivariate logistic regression indicated 8-, 4-, and 3 times higher odds ratio for development of study end-point in patients without a HTN history, with MI history, and RDW 15% (median) respectively. Thus in AHFRS, 2 points were assigned for absence of HTN history, 1 point for presence of MI history, and 1 point for RDW values 15% (0 best possible, whereas 4 worst possible score). Xanthopoulos et al, Int J Cardiol 2016

37 Risk Stratification in Acute Heart Failure There is a need for prognostic algorithms to guide the care for HF patients because physicians might incorrectly estimate risk or might be uncertain about their predictions. Clinical impression regarding prognosis is often inferior to multivariate risk algorithms. D Lee et al Can J of Cardiol 2014

38 TAKE HOME MESSAGES 1. Denovo (20%) >> Worsening Chronic HF (80%) 2. Sup-types: Worsening Chronic HF > AHF after ACS> Hypertensive HF >Pulmonary Edema > Right Heart Failure > Cardiogenic Shock. 3. Mortality Risk Factors: Demographics: Age, Sex, Socioeconomic status. Medical History: Previous HF, Etiology, Comorbidities. Symptoms & Signs: Congestion, Blood Pressure, Heart Rate, Low Cardiac Output, Low SVO 2, Low BMI Laboratory: Anemia, low Sodium, High Urea, High Creatinine, High BNP, High Troponin 4. Risk Scores Use the simpler scores (ADHERE Registry + Optimize Registry)

39 Clinical Features of AHF Syndromes Dickstein K, et al Eur Heart J 2008

40 Comorbidities in AHF Menz et al Heart Fail Clin 2013

41 Myeloperoxidase (MPO) for Risk Stratification in AHF Myeloperoxidase is a biomarker of inflammation and oxidative stress produced by neutrophils, monocytes. Concentrations of MPO predict mortality in patients with chronic heart failure. MPO is not helpful in AHF diagnosis because concentrations are similar in AHF and patients with noncardiac dyspnea, MPO concentrations were found to independently predict 1-year mortality in patients with AHF and to improve the risk stratification provided by BNP through identification of patients with a good prognosis despite increased BNP concentrations. Reichlin T et al, Clinical Chemistry 56:6 (2010)